Wingate At Sharon

F-F686

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or 34145 potential for actual harm Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment Residents Affected - Few was accurately completed to reflect the status for one Resident (#23), in a total sample of 18 residents. Specifically, the facility failed to ensure the MDS accurately reflected the Resident's pressure ulcer risk.

Findings include:

Resident #23 was admitted to the facility in July 2017 and had diagnoses including chronic kidney disease and adult failure to thrive.

Review of a Norton Plus Pressure Ulcer Scale, dated 4/23/24, indicated Resident #23 had a score of 6.0 (score of less than 10 is very high risk) and was at Very High Risk for developing pressure ulcers.

Review of the most recent MDS assessment, dated 4/25/24, indicated Section M-Skin Conditions section M0150 (risk of pressure ulcers) question: Is this resident at risk for developing pressure ulcers? The answer was documented No.

During an interview on 6/10/24 at 8:33 A.M., the MDS Coordinator reviewed section M of Resident #23's 4/25/24 MDS and the Norton Pressure Ulcer Risk assessment, dated 4/23/24. She said the Resident scored

a 6.0 which indicated a high risk for developing pressure ulcers. She said she clicked No by mistake on the 4/25/24 MDS assessment for pressure ulcer risk and needed to do a modification to the MDS to accurately reflect the Resident's risk.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 34145

Residents Affected - Few Based on record review, interviews, and policy review, the facility failed to ensure care plans were reviewed with the interdisciplinary team (IDT) as required for one Resident (#23), out of a total sample of 18 residents. Specifically, for Resident #23, the facility failed to ensure the comprehensive care plan was revised to reflect

a newly developed Stage 2 pressure ulcer (PU- partial thickness skin loss with exposed dermis) and a change in treatment.

Findings include:

Review of the facility's policy titled Comprehensive Care Plans, revised April 2022, included but was not limited to:

- The comprehensive, person-centered care plan is developed within seven days of the completion of the comprehensive assessment (MDS).

-Assessments of residents are ongoing and care plans are revised as information about the residents and

the residents' condition change.

- The Interdisciplinary team must review and update the care plan:

a. When there has been a significant change in the residents' condition.

b. When the desired outcome is not met.

c. When the resident has been readmitted to the facility from a hospital stay; and

d. At least quarterly, in conjunction with the required quarterly MDS assessment, that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident.

Resident #23 was admitted to the facility in July 2017 and had diagnoses including Alzheimer's disease and Moisture Associated Skin Damage (MASD) on the left buttock.

Review of the Minimum Data Set (MDS) assessment, dated 4/25/24, indicated Resident #23 was dependent

on staff for turning and repositioning and was non-ambulatory. The MDS also indicated that Resident #23 had MASD and utilized a pressure-reducing device in bed.

Review of the comprehensive care plans indicated but was not limited to the following:

FOCUS: Resident has bowel/bladder incontinence related to dementia, impaired mobility (4/11/21).

GOAL: Resident will remain free from skin breakdown due to incontinence.

INTERVENTIONS: Clean peri-area with each incontinence episode.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 FOCUS: Resident has impaired functional mobility related to bilateral upper extremity contractures and one side lower extremity contracture, weakness (7/31/21). Level of Harm - Minimal harm or potential for actual harm GOAL: Safety will be comfortable in environment and have no skin breakdown.

Residents Affected - Few INTERVENTIONS: Totally dependent for positioning in bed and chair.

FOCUS: Skin: Actual alteration in skin integrity related to left buttock (4/1/24).

GOAL: Resident will have signs of healing and/or resolution of non-pressure skin issue.

INTERVENTIONS: Consult and treatment by Certified Wound Medical Doctor (MD) or Certified Wound Nurse as needed (prn); observe for signs/symptoms of infection and report to MD and obtain prescription (Rx); weekly documented skin check.

Review of the medical record indicated Resident #23 was seen weekly by the facility's Wound Care consultant for evaluation of MASD.

Review of Resident #23's medical record included a Skin Observation Tool, dated 5/29/24 and completed by Nurse #1, which indicated newly identified open areas on the Resident's coccyx.

Review of the Wound Care consultant's note, dated 6/4/24, indicated Resident #23's MASD to the left buttock deteriorated to a Stage 2 pressure ulcer (partial thickness skin loss with exposed dermis) on the left ischial tuberosity (bone in the lower part of the pelvis that absorbs weight when you sit). The wound measured: 4 cm in length x 3cm width x 0.2 cm depth, had moderate serous exudate and [NAME] (sic) discoloration with biofilm (forms when microorganisms adhere and proliferate on the surface of the skin). The Wound Care consultant note also indicated that the wound is expected to heal and the plan of care was discussed with staff. Treatment recommendations for the stage 2 PU indicated the following instructions:

-Incontinence care

-Apply skin prep to periwound.

-Apply Collagen powder and calcium alginate with silver, and cover with sacral dressing daily and as needed (prn).

Further review of comprehensive care plans failed to indicate the comprehensive care plan was reviewed and revised when a Stage 2 PU was identified by the Wound Care consultant with a recommendation for a change in treatment.

During an interview on 6/7/24 at 11:37 A.M., Nurse #1 said she did not update the comprehensive care plan to reflect the change in the Resident's skin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or 49428 potential for actual harm Based on record review and interview, the facility failed to implement the Physician's order to monitor blood Residents Affected - Few glucose levels three times per day before meals for one Resident (#34), out of a sample of 18 residents.

Findings include:

Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated but was not limited to:

Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error.

Resident #34 was admitted to the facility in May 2024 with diagnoses which included type two diabetes mellitus without complications, cerebral infarction (stroke), pneumonia, and dysarthria/anarthria (the inability to produce clear, articulate speech).

Review of the Minimum Data Set (MDS) assessment, dated 5/25/24, indicated Resident #34 had a Brief

Interview for Mental Status (BIMS) score of 6 out of 15, which is indicative of severe cognitive impairment. Further review of the MDS indicated Resident #34 received insulin as ordered by the physician.

Review of Resident #34's current Physician's orders included:

-Levemir FlexPen subcutaneous solution pen-injector, 100 units/milliliter (mL). Inject 6 units subcutaneously two times a day for control of high blood sugar; start date 5/22/24.

-Metformin oral tablet 500 milligrams (mg). Give 1 tablet by mouth two times a day for blood sugar, please administer with meals; start date 5/22/24.

-Fingersticks (a procedure for obtaining blood to measure a numeric blood glucose level) before meals for diabetes; start date 5/24/24.

-Please check fasting sugars before meals for type two diabetes; start date 6/4/24.

Further review of Resident #34's medical record indicated but was not limited to:

-On 5/23/24, the Physician entered the order for fingersticks three times daily before meals into the Electronic Health Record (EHR).

-On 5/27/24, Nurse #4 confirmed the Physician's order for fingersticks three times daily before meals.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Review of Resident #34's May and June 2024 Medication Administration Record (MAR) indicated:

Level of Harm - Minimal harm or -Resident #34 received Levemir and Metformin as ordered by the Physician. potential for actual harm -No documentation of fingersticks having been performed from 5/24/24 through 6/3/24. Residents Affected - Few -No documentation of blood glucose values between 5/24/24 through 6/3/24.

Review of Physician's assessment notes on the following dates indicated but was not limited to the following:

5/22/24 - Clinical Assessment: High risk of diabetes complications.

Plan: Diabetes- patient was resumed on Metformin and Lantus (the brand name for Levemir). Fingersticks should be monitored before meals.

5/24/24 - Clinical Assessment: High risk of diabetes complications.

Plan: Fingersticks should be monitored before meals. I ordered fingersticks three times a day before meals.

Review of Nurse Practitioner's assessment note, dated 6/4/24, indicated but was not limited to:

Clinical Assessment - Type 2 diabetes mellitus with unspecified complications. He/she is on Levemir and Metformin. There is an order to check fingersticks before meals, but results not recorded in EHR. I have updated the order so results will be in EHR.

Review of Resident #34's medical record indicated no documentation of fingersticks or blood glucose values from 5/24/24 until 6/4/24 at 7:44 P.M. at which time the first fingerstick was documented with a value of 201 mg/deciliter (dL). The total of missed fingerstick opportunities during this timeframe was 35.

During an interview on 6/11/24 at 10:23 A.M., Nurse #4 said when a Physician enters a medication or treatment order into the EHR, nursing would see the order, in red print, and would confirm the order. Nurse #4 said for Resident #34, she confirmed the Physician's fingerstick order on 5/27/24. Nurse #4 said nursing documented fingersticks and blood glucose values in the EHR. Nurse #4 and the surveyor reviewed the Resident's EHR and Nurse #4 said she could not find documentation of fingersticks being performed or blood glucose values prior to 6/4/24.

During a telephonic interview on 6/11/24 at 1:06 P.M., the Physician said she would expect staff to implement her recommendations to monitor Resident #34's blood sugars three times a day before meals beginning 5/24/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 During an interview on 6/11/24 at 4:15 P.M., the Director of Nursing (DON) said when a Physician enters an order into the EHR, nursing must confirm and implement the order. The DON said the Physician's order for Level of Harm - Minimal harm or fingersticks was confirmed by Nurse #4 on 5/27/24. The DON said he expected nursing to have confirmed potential for actual harm and implemented this order within 24 hours after the Physician entered it. The DON said he could not find documentation of fingersticks being performed per Physician's order or blood glucose values from 5/24/24 Residents Affected - Few through 6/3/24. The DON said he expected to at least see documentation for fingersticks and blood glucose values beginning on 5/27/24 since nursing confirmed the order on 5/27/24.

During an interview on 6/12/24 at 11:01 A.M., the DON said he would expect nursing to be cognizant in this situation and realize Resident #34 was not receiving fingersticks or blood glucose monitoring per Physician's orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 34145

Residents Affected - Few Based on observations, interviews, and records reviewed, the facility failed to ensure one Resident (#23), out of a total sample of 18 residents, received care and treatment to prevent and to promote healing of a pressure injury consistent with professional standards of practice. Specifically, the facility failed to implement treatments as ordered and notify the physician of worsening Moisture-Associated Skin Damage (MASD-inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine or stool) resulting in a delay in treatment and deterioration of the wound to a stage 2 pressure ulcer (PU- partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) to the Resident's left ischial tuberosity (bone in the lower part of the pelvis that absorbs weight when you sit).

Findings include:

Review of the facility's policy titled Pressure Ulcer/Injury Risk Assessment, revised March 2022, indicated but was not limited to the following:

-Risk factors that increase a resident's susceptibility to develop or to not heal PU/PIs include but are not limited to impaired/decreased mobility and decreased functional ability

-Once the assessment is conducted and risk factors are identified and characterized, a resident-centered care plan can be created to address the modifiable risks for pressure ulcers/injuries

-Conduct a comprehensive skin assessment with every risk assessment

-The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate

Documentation:

-The type of assessment conducted

-Any change in the resident's condition, if identified

-The condition of the resident's skin (i.e., the size and location of any red or tender areas), if identified

-Initiation of a (pressure or non-pressure) form related to the type of alteration in skin if new skin alteration noted

-Documentation in the medical record addressing MD notification if new skin alteration noted with change of plan of care, if indicated

-Report other information in accordance with facility policy and professional standards of practice

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Resident #23 was admitted to the facility in July 2017 and had diagnoses including Alzheimer's disease and MASD on the left buttock. Level of Harm - Actual harm

Review of the Minimum Data Set (MDS) assessment, dated 4/25/24, indicated Resident #23 had short and Residents Affected - Few long-term memory problems, severely impaired cognitive skills for daily decision making, was dependent on staff for turning and repositioning and was non-ambulatory. The MDS also indicated that Resident #23 had MASD and utilized a pressure reducing device in bed.

Review of a Norton Plus Pressure Ulcer Scale, dated 4/23/24, indicated Resident #23 had a score of 6.0 (score of less than 10 is very high risk) and was at very high risk for developing pressure ulcers.

Review of the comprehensive care plans indicated but was not limited to the following:

FOCUS: Resident has bowel/bladder incontinence related to dementia, impaired mobility (4/11/21).

GOAL: Resident will remain free from skin breakdown due to incontinence.

INTERVENTIONS: Clean peri-area with each incontinence episode.

FOCUS: Resident has impaired functional mobility related to bilateral upper extremity contractures and one side lower extremity contracture, weakness (7/31/21)

GOAL: Safety will be comfortable in environment and have no skin breakdown.

INTERVENTIONS: Totally dependent for positioning in bed and chair.

FOCUS: Skin: Actual alteration in skin integrity related to left buttock (4/1/24).

GOAL: Resident will have signs of healing and/or resolution of non-pressure skin issue.

INTERVENTIONS: Consult and treatment by Certified Wound Medical Doctor (MD) or Certified Wound Nurse as needed (prn); observe for signs/symptoms of infection and report to MD and obtain prescription (Rx); weekly documented skin check.

Further review of comprehensive care plans failed to indicate a care plan for pressure ulcer risk had been developed.

Review of the medical record indicated Resident #23 was seen weekly by the facility's Wound Care consultant.

Review of the Wound Care Consultant's note, dated 4/2/24, indicated the MASD to the Resident's left buttock measured 2.5 centimeters (cm) in length x 0.5 cm in width x 0.1 cm depth, had scant serous exudate (clear or slightly yellow wound drainage) and was macerated (softening and breaking down of skin resulting from prolonged exposure to moisture) due to incontinence. The Wound Care consultant indicated the wound is expected to heal and the plan of care was discussed with staff. Treatment recommendations for the MASD indicated the following instructions:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 -Incontinence care.

Level of Harm - Actual harm -Pat dry.

Residents Affected - Few -Apply collagen powder (supports new blood vessel formation, granulation tissue formation, the debridement of the wound and the ability of the wound to re-epithelize) with barrier cream twice a day (BID).

Review of the Physician's Orders/treatment administration record (TAR) indicated the order was implemented on 4/2/24.

Review of the medical record indicated the Wound Care Consultant saw Resident #23 on 4/9/24, 4/16/24 and 4/23/24 with no new treatment recommendations for the MASD.

Review of the Wound Care Consultant's note, dated 4/30/24, indicated the MASD to the Resident's left buttock measured 5 cm in length x 3 cm in width x 0.2 cm depth, had moderate serous exudate and was macerated. The Wound Care consultant indicated the wound is expected to heal and the plan of care was discussed with staff. Treatment recommendations for the MASD indicated the following instructions:

-Incontinence care.

-Pat dry.

-Skin prep (a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes and films) to periwound (the area around the wound).

-Apply collagen powder, calcium alginate with silver (used for moderate to heavily exuding, partial- to full-thickness wounds including pressure injuries)

-Cover with border dressing daily and prn.

Review of the Physician's Orders/treatment administration record (TAR) indicated the order was implemented on 5/2/24, two days after the recommendation was made.

Review of the Wound Care Consultant's note, dated 5/7/24, indicated the MASD to the Resident's left buttock measured 3 cm in length x 3 cm in width and had no exudate and the tissue was 100% epithelial (thin layer of tissue that covers organs, glands, and other structures within the body). The Wound Care consultant indicated the wound is expected to heal and the plan of care was discussed with staff. Treatment recommendations for the MASD indicated the following instructions:

-Incontinence care.

-Apply barrier cream twice daily and prn

Further review of the medical record failed to indicate Resident #23's attending physician/NP was notified of

the Wound Care consultant's recommendation for a change in treatment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Review of the Physician's Orders/treatment administration record (TAR) indicated the previous order was not discontinued and continued to be administered until 5/30/24, 23 days after the Wound Care consultant Level of Harm - Actual harm recommended a new treatment.

Residents Affected - Few According to the National Institute of Health (2012), it is recommended that silver dressings should be used for 2 weeks initially and then the wound, the patient, and the management approach should be re-evaluated.

Review of the complete medical record failed to indicate the Resident was seen by the Wound Care consultant on 5/14/24.

Review of the Nurse Practitioner (NP)'s Progress note, dated 5/14/24, indicated Resident #23 had a wound to his/her left buttock due to moisture-associated dermatitis, the wound is epithelialized, and the Resident is followed by the wound specialist. The NP's assessment indicated Resident #23 was at high risk for further skin breakdown and moisture-associated dermatitis due to his/her immobility and incontinence and to continue barrier cream and prompt incontinence care.

Review of the medical record indicated the Wound Care Consultant saw Resident #23 on 5/21/24 with no new treatment recommendations for the MASD.

Review of the Wound Care Consultant's note, dated 5/28/24, indicated the MASD to the Resident's left buttock had increased in size and measured 7 cm in length x 4 cm in width x 0.2 cm in width, had scant serous exudate, and the tissue was 100% dermis (composed of connective tissue). The Wound Care Consultant's note indicated that the wound is expected to heal and the plan of care was discussed with staff. New treatment recommendations for the MASD indicated the following instructions:

-Incontinence care

-Apply skin prep to periwound

-Apply wound gel and cover with sacral dressing daily and prn

Further review of the medical record indicated the Wound Care Consultant's treatment recommendation was implemented on 5/31/24, three days after the Wound Care Consultant recommended a change in treatment.

Review of the Wound Care consultant's note, dated 6/4/24 and signed at 4:08 P.M., indicated Resident #23's MASD to the left buttock deteriorated to a Stage 2 pressure ulcer on the left ischial tuberosity. The wound measured: 4 cm in length x 3 cm width x 0.2 cm depth, had moderate serous exudate and [NAME] (sic) discoloration with biofilm (forms when microorganisms adhere and proliferate on the surface of the skin). The Wound Care Consultant's note also indicated that the wound is expected to heal and the plan of care was discussed with staff. Treatment recommendations for the stage 2 PU indicated the following instructions:

-Incontinence care

-Apply skin prep to periwound.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 -Apply Collagen powder and calcium alginate with silver, and cover with sacral dressing daily and prn.

Level of Harm - Actual harm Review of a Weekly Wound Rounds document, dated 6/5/24 and signed as complete by the Director of Nursing (DON), indicated Resident #23 had acquired a stage 2 pressure ulcer to the left ischium with Residents Affected - Few moderate serous drainage and measured 4 cm in length x 3 cm in width x 0.2 cm in depth. The note indicated the physician was notified of the stage 2 PU on 6/5/24. The document indicated the current treatment plan was:

-Incontinence care.

-Apply skin prep to periwound.

-Apply collagen powder and calcium alginate with silver and cover with sacral dressing daily and prn.

Review of a 6/6/24 Late Entry Note, written by the DON at 7:11 A.M., indicated Resident #23 continues to have MAD (Moisture Associated Dermatitis) to the coccyx area. Dressing changed as ordered. The noted failed to indicate Resident #23 had a stage 2 PU to his/her left ischium tuberosity.

During a treatment observation on 6/6/24 at 2:07 P.M., the surveyor observed Nurse #1 perform a dressing change to Resident #23's left ischium wound. The wound bed had a mostly beefy-red wound base with a small amount of tan slough (non-viable yellow, tan, gray, green or brown tissue) present. Nurse #1 checked

the orders in the medical record and applied wound gel to the wound base and it was covered with a silicone super absorbent dressing.

Review of a Nurse's Note, dated 6/6/24, indicated the dressing was changed to Resident #23's left buttock.

The old dressing had scant sanguineous drainage and small slough (dead tissue, usually cream or yellow in color) was noted on the wound.

During an interview on 6/7/24 at 11:38 A.M., the DON said the Wound Care Consultant comes into the facility every Tuesday and the Assistant Director of Nursing (ADON) usually rounds with them. He said if there were any changes with a wound and new treatment recommendations, the consultant would inform the ADON during the visit. He said they would wait for the Wound consultant to send their note, then contact the physician with treatment recommendations. The DON reviewed the Weekly Wound Round note, dated 6/5/24, that he completed. He said he spoke to the physician, and she approved the Wound Care Consultant's recommendations. He could not explain why the treatment orders were not entered into the electronic medical record until 6/7/24. He said he should have entered the orders when he received them from the Physician on 6/5/24.

During an interview on 6/7/24 at 11:52 A.M., the ADON said on Tuesday, when the Wound Care consultant was in the facility, she was too busy to round with her and didn't see Resident #23's wound and was not told

the Resident developed a stage 2 PU. She said she saw the Wound Care NP in the hallway and she told her

she was going to recommend a change in treatment. The ADON said the Wound Care consultant's notes are sent to the DON who then puts it in the Resident's medical record. She said she didn't see the report until yesterday (6/6/24), and after she got home, she entered the order into Resident #23's medical record without first contacting the Physician and obtaining an order for the treatment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 During a telephone interview on 6/7/24 at 12:17 P.M., Physician #1 said she usually reviews the Wound Care consultant reports but has not had a chance to review Resident #23's report yet. She said she had not Level of Harm - Actual harm spoken to the DON or anyone else to inform her that Resident #23 had developed a stage 2 PU and the Wound Care consultant had new treatment recommendations. Physician #1 said when she is not there, the Residents Affected - Few NP is there and they may have notified her. She said if the NP was told about it, she would have written a note in daily rounding notes. The Physician said she was looking in Resident #23's medical record on her computer and said the NP had not written a note regarding Resident #23. She said she could only see the note from the Wound Care provider. She said her expectation is that facility staff would call either her or the NP with a change in condition and/or change in treatment either the day the recommendation is made, or no later than the following day. She said for a recommendation made on 6/4/24, it should not take until 6/7/24 to communicate the information and implement the new treatment.

During a telephone interview on 6/7/24 at 12:50 P.M., the NP said she was in the facility on 6/4/24 and did not see the Wound Care consultant. She said she was in the facility yesterday (6/6/24) and was not notified that Resident #23 had developed a new stage 2 PU or was made aware of any treatment recommendations by the Wound Care consultant. The NP said she does not receive a copy of Wound Care consultant reports.

She said she thinks they get emailed to the DON.

On 6/7/24 at 12:38 P.M., a voice message was left for the Wound Care Consultant with no return call.

Review of the medical record indicated a Nurse's Note, dated 6/7/24, indicated Corporate staff #1 contacted Physician #1 regarding the Wound Care consultant's treatment recommendation from the last visit on 6/4/24.

The Physician agreed to the recommendation.

Review of the medical record indicated the following Physician's order was entered into the electronic medical record on 6/7/24, three days after the recommendation was made:

-Left buttock: skin prep, apply collagen powder and calcium alginate with silver, cover with sacral dressing daily/prn.

Review of the June 2024 Treatment Administration Record (TAR) indicated this order was not initiated until 6/8/24, four days after the Wound Care consultant made the recommendation for a change in treatment for

the newly acquired stage 2 PU.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm 34145

Residents Affected - Few Based on observation and interview, the facility failed to ensure staff provided residents an environment free from accident hazards on one unit (Borderland) of three units in the facility. Specifically, the facility failed to ensure a storage closet and storage area in the shower room was securely locked and hazardous items were not easily accessible to wandering residents.

Findings include:

On 6/6/24 at 8:16 A.M., the surveyor observed three residents wandering the hallways of the Borderland Unit (secure Dementia Special Care Unit).

On 6/6/24 at 8:30 A.M. on the Borderland Unit, the surveyor approached a closed door labeled shower room and entered. Inside the shower room was a storage room with a closed door. The door was unlocked. The surveyor observed the following items in the unlocked and unsecured storage room:

-Two oxygen concentrators

-2 filled portable oxygen tanks

-Three-tiered cart with drawers that contained a bottle of shampoo & body wash and a bottle of Difeel Biotin Pro-Growth Shampoo.

On 6/6/24 at 9:29 A.M., the surveyor approached a closed door near the unit bathroom. The door had a numerical combination lock on it, but the door was not pulled tight and secured and was easily pushed open.

The surveyor observed the following items in the unlocked and unsecured storage closet:

-An open box containing packages of disposable razors was on the shelf

-Two bottles of moisturizing body lotion

-Five packets of A & D ointment skin protectant

-One bottle of mouthwash

-One can of shaving cream

At the conclusion of the observation, the surveyor pulled the door closed tightly and ensured the storage closet was secured.

On 6/11/24 at 8:25 A.M., the surveyor approached a closed door near the unit bathroom. The door had a numerical combination lock on it, but the door was not pulled closed and secured and was easily pushed open.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On 6/11/24 at 8:26 A.M., the surveyor and Activity Director observed the unlocked and unsecured storage closet. She said the door to the storage closet and storage room in the shower room should be closed so Level of Harm - Minimal harm or residents can't access items that may be hazardous. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46562 Residents Affected - Few Based on observations, interviews, and records reviewed, for one Resident (#36), of 18 sampled residents,

the facility failed to provide Foley catheter (a tube inserted through the urinary tract into the bladder, connected to a drainage bag to drain urine from the bladder) care and management consistent with professional standards of practice. Specifically, for Resident #36, the facility failed to:

-Ensure his/her Foley catheter was properly positioned to ensure adequate drainage from the bladder,

-Document care and maintenance of a Foley catheter,

-Implement provider orders for Intake and Output (I&O) monitoring to ensure adequate output, and

-Notify his/her provider of an abnormal radiology report resulting in Resident #36 being hospitalized for four days due to a malpositioned (wrong or faulty position) Foley catheter resulting in bilateral hydroureteronephrosis (swelling of both kidneys and ureters, a thin tube that drains urine from the kidney to

the bladder, which occurs when urine can't drain and builds up in the kidneys and ureters), impaired kidney function, and a urinary tract infection.

Findings include:

Review of the facility's policy titled Intake Monitoring, dated as revised 4/2022, indicated but was not limited to:

-the purpose of this procedure is to accurately determine the amount of liquid a resident consumes in a 24-hour period

-at the end of your shift, total the amounts of all liquids the resident consumed in the clinical record

Review of the facility's policy titled Output Monitoring, dated as revised 4/2022, indicated but was not limited to:

-the purpose of this procedure is to accurately determine the amount of urine that a resident excretes in a 24-hour period

-pour or drain the urine from the bedpan, urinal, or catheter into the graduate (measuring container)

-record the amount noted on the output side of the intake and output record

-document in the clinical record amount of output

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Review of the facility's policy titled Catheter Care, dated as revised 4/2022, indicated but was not limited to:

Level of Harm - Actual harm -perform twice daily with A.M. and P.M. care, and as needed after incontinence or bowel movements

Residents Affected - Few Review of the facility's policy titled Indwelling Catheter Care, dated as revised 4/2022, indicated but was not limited to:

-catheter care will be performed at least daily and as needed (PRN) and in accordance with a physician's and/or nursing order.

Review of Human Anatomy & Physiology, Ninth Edition, Urinary Bladder, indicated that a moderately full bladder holds approximately 500 milliliters of urine but can hold nearly double that if necessary. The maximum capacity of the bladder is [PHONE NUMBER] milliliters and when it is over distended it may burst.

Review of Lippincott Manual of Nursing Practice, Eleventh Edition, Catheterization Procedure, indicated that

a urinary catheter should be inserted 6 to 10 inches and advanced another 1 inch once urine flow is observed.

Resident #36 was admitted to the facility in February 2024 with the following diagnoses: dementia and neurogenic bladder (a urinary dysfunction in which the bladder does not empty properly in which the bladder may empty spontaneously or may not empty at all).

Review of the Minimum Data Set (MDS) assessment, dated 3/22/24, indicated Resident #36 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 1 out of 15, and had

an indwelling catheter.

Review of Resident #36's care plans indicated but was not limited to:

-Focus: Resident #36 has a urinary catheter related to obstructive uropathy (condition in which the flow of urine is blocked) and was at risk for developing complications, dated 3/30/24 and revised 6/11/24.

-Goal: Resident will have no signs or symptoms of complications from the use of catheter through next review, dated 3/30/23

-Interventions:

1. Follow up with urology as indicated, dated 3/30/24

2. Monitor labs ordered and report results to physician, dated 3/30/24

3. Provide catheter care every shift, dated 3/30/24

Further review of Resident #36's March 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) failed to indicate documented evidence that the facility provided Foley catheter care and maintenance of the Foley catheter.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 During an interview on 6/11/24 at 10:23 A.M., Nurse #4 said a resident with a Foley catheter should have orders for the care and maintenance of the Foley catheter. Nurse #4 said the electronic medical record Level of Harm - Actual harm should have documented evidence of the care and maintenance of the Foley catheter.

Residents Affected - Few Review of Resident #36's Encounter Note, written by Physician #1 and dated 3/11/24, indicated but was not limited to:

-Urinary retention, suspect neurogenic bladder. The Foley catheter is draining well. He/she should follow-up with urology as an outpatient.

Review of Resident #36's Skilled Nursing Note, dated 3/11/24, indicated but was not limited to:

-His/her partner is currently with him/her. Intermittent screaming noted, redirected with no effect.

Review of Resident #36's Encounter Note, written by Nurse Practitioner (NP) #1 and dated 3/12/24, indicated but was not limited to:

-Foley catheter was changed last night due to concern that urine was not draining properly.

-Nursing reports catheter has been putting out adequate amount of urine today.

-Upon my exam he/she has approximately 400 milliliters (ml) clear yellow urine in drainage bag and does not have any palpable bladder distention or suprapubic tenderness.

-He/she denies urinary or suprapubic discomfort.

-Nursing reports he/she is moving his/her bowels.

-Received a call this afternoon that his/her significant other was still concerned he/she was retaining urine but nursing reports he/she does not appear to have any bladder distention.

-Unfortunately, the facility does not have a bladder scanner (a noninvasive tool used to measure urine volume in the bladder).

-Asked nursing to place resident on Intake and Output (I&O) for 2 days so we can ensure he/she was drinking enough fluids and putting out enough urine.

Review of Resident #36's Nursing/Health Status Note, dated 3/12/24, indicated but was not limited to:

-Seen by NP new order for I&O to monitor fluids intake.

Review of Resident #36's March 2024 MAR and TAR failed to indicate documented evidence that I&O monitoring occurred between 3/12/24 and 3/15/24.

Review of Resident #36's orders failed to indicate evidence that I&O monitoring was ordered between 3/12/24 and 3/15/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 During an interview on 6/12/24 at 8:35 A.M., Nurse #4 said when a resident was on I&O monitoring there would be an order in the electronic medical record the nurses would record and monitor the total amount Level of Harm - Actual harm every shift.

Residents Affected - Few During an interview on 6/12/24 at 8:14 A.M., the Assistant Director of Nurses (ADON) said if an order is given for I&O monitoring, the order will be put into the electronic medical record. The nurse will calculate what the patient drinks and tally it daily. The Certified Nursing Assistants (CNA) document in the electronic

record but the nurse is responsible for totaling and entering the total in the resident's record.

During an interview on 6/11/24 at 11:05 A.M., NP #1 said she had been following Resident #36 for a concern with urinary retention and she believed nursing was monitoring I&O. NP #1 said she saw Resident #36 the day before his/her hospitalization and observed urine in the drainage bag.

Review of Resident #36's Skilled Nursing Note, dated 3/12/24, indicated but was not limited to:

-His/her partner is currently with him/her. Intermittent screaming noted, redirected with no effect.

Review of Resident #36's Encounter Note, written by Physician #1 and dated 3/13/24, indicated but was not limited to:

-Yesterday his/her family spoke to nursing about concern that his/her Foley was not putting out enough urine despite adequate fluid intake.

-Nursing did change Foley catheter. Foley catheter was changed on 3/11 due to concern that urine was not draining properly.

-Today nursing reports Foley does appear to be putting out an adequate amount of urine.

-Patient is a limited historian but denies any suprapubic discomfort or feeling like he/she is retaining urine.

Review of Resident #36's Skilled Nursing Note, dated 3/13/24, indicated but was not limited to:

-His/her partner is currently with him/her. Intermittent screaming noted, redirected with no effect.

Review of Resident #36's Encounter Note, written by NP #1 and dated 3/14/24, indicated but was not limited to:

-Chief complaint/nature of presenting problem was abdominal distention.

-His/her significant other was concerned last weekend that his/her Foley was not putting out enough urine despite adequate fluid intake.

-Nursing changed the Foley catheter on 3/11.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 -Today nursing reports Foley is putting out an adequate amount of urine. Patient is a limited historian but denies any super pubic discomfort or feeling like he/she retaining urine. Level of Harm - Actual harm -Upon exam his/her abdomen is noted to be distended and firm. He/she does report mild abdominal pain. Residents Affected - Few He/she cannot tell me when his/her last bowel movement was.

-Foley draining clear yellow urine, no palpable bladder distention or suprapubic tenderness.

-Plan: abdomen is firm and distended on exam today. He/she has a history of significant constipation and is

on an aggressive bowel regimen. Ordered a fleet enema (liquid medication used to help someone have a bowel movement, a laxative) times one now and a stat X- ray of his/her abdomen including the kidneys, ureter and bladder (KUB) to assess for ileus (the inability of the intestine to contract normally leading to a build-up of food material)/obstruction.

Review of Resident #36's Nurse's Note, dated 3/14/24, indicated but was not limited to:

-One time enamel [SIC] given for constipation; he/she had a large bowel movement (BM). New order to obtain KUB, KUB done this afternoon, results pending.

Review of Resident #36's KUB radiology report, dated 3/14/24, indicated but was not limited to:

Findings: Air is scattered in the colon with minimal dilation of a few bowel loops. No significant small bowel areas seen. There is a soft tissue density arising out of the pelvis to the level of the fourth lumbar vertebra. No other masses or significant calcifications are seen. No fecal retention is seen.

Conclusion: There is nonspecific bowel gas pattern. A minimal ileus of the colon may be present. There is a soft tissue density arising out of the pelvis which could be an abnormally distended urinary bladder or possibly a pelvic mass. Pelvic ultrasound is recommended for further evaluation.

Further review of Resident #36's KUB radiology report, dated 3/14/24, indicated:

-examination date: 3/14/24 at 16:09

-reported date: 3/14/24 at 16:26

During a telephonic interview on 6/13/24 at 11:19 A.M., the Laboratory/Radiology Services Consultant said

the KUB results were faxed to the unit that Resident #36 was residing on on 6/13/24 at 16:29.

Review of Resident #36's Encounter Note, written by Physician #1 and dated 3/15/24, indicated but was not limited to:

-Upon exam his/her abdomen is noted to be distended and firm.

-He/she does report mild abdominal pain.

-I have personally reviewed all the available labs and tests.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 -KUB revealed a nonspecific bowel gas pattern. A minimal ileus of the colon may be present. There is a soft tissue density arising out of the pelvis which could be an abnormally distended urinary bladder or possibly a Level of Harm - Actual harm pelvic mass. Pelvis ultrasound is recommended for further evaluation.

Residents Affected - Few -Plan: Abdomen is nontender, but firm and distended on exam today. He/she is a poor historian but does report mild abdominal pain. Foley catheter is draining clear yellow urine. No signs of urinary obstruction. Nursing changed the Foley catheter on 3/11. A pelvic ultrasound cannot be obtained at our facility in the next 48 hours due to being a weekend, so I would advise hospital transfer.

Review of Resident #36's medical record failed to indicate facility staff notified the provider of the KUB results prior to the physician visit on 3/15/24.

During an interview on 6/11/24 at 1:01 P.M., Physician #1 said on 3/15/24 she reviewed Resident #36's KUB report and called the significant other due to concerning results. Physician #1 said the Resident needed to be sent to the hospital because an ultrasound needed to be obtained. Physician #1 said prior to the Resident's transfer urine was observed in the drainage bag. Physician #1 said it was possible for urine to continue to accumulate in the drainage bag even if the catheter was displaced. Physician #1 said the hospital staff replaced the Foley catheter which resolved the Resident's issues.

Review of Resident #36's Interdisciplinary Team (IDT) Discharge & Recapitulation Summary, dated 3/15/24, indicated but was not limited to:

-Resident was transferred to hospital related to a distended abdomen

Review of Resident #36's Hospital paperwork, specifically the Patient Visit Information, dated 3/17/24, indicated but was not limited to:

-He/she was admitted for malfunctioning urinary catheter.

-His/her catheter was replaced and it is now functioning properly.

-He/she was also noted to have been constipated but has been moving his/her bowels.

-He/she was noted to have a urinary tract infection which was treated.

Review of Resident #36's Hospital paperwork, specifically the Discharge Summary, dated 3/18/24, indicated but was not limited to:

-Resident #36 was transferred to rehab 1.5 weeks prior and 3-4 days ago the healthcare proxy (HCP) noticed Resident #36 was having progressively worsening distention of his/her bladder which then progressed to having worsening oral intake and poor participation in physical therapy. HCP also noted diaphoresis (excessive or abnormal sweating for no apparent reason) and he/she was complaining of difficulty urinating.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 -In the Emergency Department, Resident #36 was mildly tachycardic (a heartrate greater than 100 beats per minute) to 106, and his/her labs showed a serum creatinine (a blood or urine test that indicates how well your Level of Harm - Actual harm kidneys are filtering waste from your blood) of 2.12 (the typical range for serum creatinine is: for adult men, 0. 74 to 1.35 milligrams/deciliter and for adult women, 0.59 to 1.04 milligrams/deciliter) and a blood urea Residents Affected - Few nitrogen (BUN, test reveals how well your kidneys are working) of 67 (a BUN of 6 to 24 milligrams/deciliter is considered normal), his/her urinalysis (a review of the urine) was grossly infected and his/her abdominopelvic computerized tomography scan (CT scan, a type of imaging that uses X-ray techniques to create detailed images of the body) indicated bilateral hydronephrosis and a distended urinary bladder with

the Foley catheter positioned within the tip of the penile urethra.

-Foley catheter was replaced and 2500 milliliters of urine was removed with improvement in his/her abdominal distention. He/she was administered antibiotics and admitted to the hospital for further management.

-Creatinine was down to 0.63 after Foley catheter decompression.

-Renal ultrasound was obtained on 3/17/24 to reassess hydronephrosis and indicated no evidence of hydronephrosis on the right (which had been on the CT scan) and bladder was decompressed.

Review of Resident #36's CT Scan Report, dated 3/15/24 at 3:37 P.M., indicated but was not limited to:

-There was bilateral hydroureteronephrosis which could have been related to the degree of the bladder distention

-The ureters were dilated at the level of the ureterovesical junction (UVJ, where the ureter meets the bladder) bilaterally.

-The urinary bladder was markedly distended.

-The bladder measured over 19 centimeters in craniocaudal (a standard view taken from above) dimension.

-There was a malpositioned Foley catheter that appeared to be within the penile urethra. Proximal to this there is a low-density which could be related to distention of the urethra versus the Foley catheter balloon.

Review of Resident #36's Encounter Note, written by NP #1 and dated 3/19/24, indicated but was not limited to:

-He/she was sent to the Hospital on 3/15/24.

-He/she was found to have bilateral hydroureteronephrosis, distended urinary bladder, and fecal loading.

-Foley catheter was changed and 2500 milliliters (mL) of urine was removed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 -He/she returned to the facility on [DATE REDACTED].

Level of Harm - Actual harm During an interview on 6/11/24 at 1:41 P.M., the Director of Nurses (DON), the Director of Clinical Services, and the surveyor reviewed Resident #36's medical record. The DON and Director of Clinical Services said Residents Affected - Few they were unable to provide documented evidence of the care and maintenance of the Foley catheter prior to 3/15/24, there was no order or documented evidence of I&O monitoring prior to 3/15/24, and there was no documented evidence from the nurse that a provider was notified of the KUB report. The DON said Resident #36 was transferred to the hospital on 3/15/24 around 11:30 A.M. due to a distended abdomen and abnormal KUB results.

Refer to

F-F838

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or 49428 potential for actual harm Based on record review, policy review, and interview, the facility failed to monitor adverse consequences of Residents Affected - Few an anticoagulation medication (used to prevent the blood from clotting, a blood thinner) prescribed for one Resident (#34), out of a total sample of 18 residents.

Findings include:

Review of the facility's policy titled Anticoagulation Therapy, revised 4/2022, indicated but was not limited to:

Monitoring and Follow-Up

-the staff and physician will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems.

-if an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant.

Resident #34 was admitted to the facility in May 2024 with diagnoses which included cerebral infarction (stroke), hypertension (high blood pressure), and dysarthria/anarthria (the inability to produce clear, articulate speech).

Review of the Minimum Data Set (MDS) assessment, dated 5/25/24, indicated Resident #34 had a Brief

Interview for Mental Status (BIMS) score of 6 out of 15, which is indicative of severe cognitive impairment. Further review of the MDS also indicated Resident #34 had received anticoagulant medication.

Review of Resident #34's current Physician's Orders indicated but was not limited to:

-Lovenox injection solution (an anticoagulant) prefilled syringe 40 milligrams (mg)/0.4 milliliters. Inject 1 vial subcutaneously one time a day for blood thinner; start date 5/22/24.

-Clopidogrel (antiplatelet) 75 mg. Give 1 tablet by mouth one time a day for blood thinner; start date 5/22/24.

-Aspirin 81 mg. Give 81 mg by mouth one time a day for prevention; start date 5/22/24.

Review of Resident #34's May 2024 and June 2024 Medication Administration Record (MAR) indicated he/she was administered Lovenox, Clopidogrel, and Aspirin as ordered.

Review of Resident #34's Physician's History and Physical Note, dated 5/22/24, indicated but was not limited to:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 -Plan: Deep Vein Thrombosis (DVT) prophylaxis - patient is on Lovenox per hospital records. He/she is at high risk of bleeding due to being on Aspirin, Plavix, and Lovenox. Level of Harm - Minimal harm or potential for actual harm Review of Resident #34's Nurse Practitioner Follow-Up note, dated 5/23/24, indicated but was not limited to:

Residents Affected - Few -Clinical Risk Assessment: High risk of bleeding complications.

-Assessment: Current use of anticoagulant therapy. Currently on Lovenox. Will need to monitor closely for signs of bleeding, especially since he/she is also on Aspirin and Plavix.

Review of Resident #34's Physician Follow-Up note, dated 5/24/24, indicated but was not limited to:

-Clinical Risk Assessment: High risk of bleeding complications.

-Plan: Deep Vein Thrombosis (DVT) prophylaxis - patient is on Lovenox per hospital records. He/she is at high risk of bleeding due to being on Aspirin, Plavix, and Lovenox.

Review of Resident #34's Nurse Practitioner Follow-Up note, dated 6/6/24, indicated but was not limited to:

-Clinical Risk Assessment: High risk of bleeding complications.

Further review of Resident #34's past and current Physician's orders, specifically during the time the Resident received anticoagulant medication, indicated there was no order for monitoring possible side effects or adverse complications related to the anticoagulant medication.

During an interview on 6/12/24 at 10:20 A.M., the Physician said it was standard to monitor for bleeding and bruising when receiving anticoagulant medication and Resident #34 should have had an order to monitor for possible complications, such as bleeding and bruising, while he/she received anticoagulant medication.

During an interview on 6/12/24 at 11:01 A.M., the Director of Nursing (DON) said Lovenox was an anticoagulant medication, and he expected residents receiving anticoagulant medication to be monitored for bleeding and bruising. The DON and the surveyor reviewed Resident #34's past and current Physician's orders. The DON said he was not able to find an order to monitor Resident #34 for adverse consequences of anticoagulation medications. The DON said Resident #34 should have had an order to monitor for adverse consequences of anticoagulation medications but did not.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or 46562 potential for actual harm Based on observations, records reviewed, policy review, and interviews, the facility failed to ensure it was Residents Affected - Few free from a medication error rate of greater than 5% when 2 out of 3 nurses observed made 2 errors out of 28 opportunities, resulting in a medication error rate of 7.14%. Those errors impacted two Residents (#29 and #1), out of four residents observed.

Findings include:

Review of the facility's policy titled Medication Administration, dated as revised 4/17, indicated but was not limited to:

-Select the drug from the unit dose drawer or stock supply.

-Check the label on the medication and confirm the medication name and dose with the Medication Administration Record (MAR).

-Check the medication dose. Re-check to confirm the proper dose.

1. For Resident #29, Nurse #2 administered the incorrect formula of Senna (a laxative medication).

On 6/10/24 at 8:40 A.M., the surveyor observed Nurse #2 prepare and administer medications to Resident #29 including:

-Senna-S (a natural vegetable laxative plus stool softener), 2 tablets

Review of Resident #29's Physician's Orders indicated he/she should have received Senna (a laxative) and not Senna-S.

During an interview on 6/10/24 at 4:37 P.M., Nurse #2 said she should have given Senna and not Senna-S because the Senna-S was a combination drug and contained Senna and Colace (a stool softener) with it.

2. For Resident #1, Nurse #3 failed to administer the Resident's Artificial Tears.

On 6/10/24 at 4:20 P.M., the surveyor observed Nurse #3 prepare but failed to administer medications to Resident #1 including:

-Artificial Tears

Review of Resident #1's Physician's Orders indicated the Resident should have received Artificial Tears.

During an interview on 6/10/24 at 4:25 P.M., Nurse #3 said she had completed the administration of the prepared medication for Resident #1 and was moving on to the next resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 During an interview on 6/10/24 at 4:41 P.M., Nurse #3 said she prepared Resident #1's Artificial Tears but did not bring them into the room during medication administration. Nurse #3 said she should have Level of Harm - Minimal harm or administered the Artificial Tears while in the Resident's room but she did not. potential for actual harm

During an interview on 6/11/24 at 10:39 A.M., the Director of Nursing (DON) said the expectation was for Residents Affected - Few medication to be administered per physician's orders.

50740

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46562 Residents Affected - Few Based on observations, interview, and policy review, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed to:

1. For Resident #51, ensure the medications were administered under direct supervision of a licensed nurse and not left at the bedside;

2. Ensure the medication and treatment carts were locked when not in direct supervision of the licensed nurse; and

3. Ensure safe storage of medications and biologicals according to current standards of practice.

Findings include:

Review of the facility's policy titled Medication Storage, dated as revised 4/22, indicated but was not limited to the following:

-Compartments (including but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

-Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys.

1. Resident #51 was admitted to the facility in June 2023 with diagnoses including asthma and shortness of breath.

Review of the Minimum Data Set (MDS) assessment, dated 3/13/24, indicated Resident #51 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out 15.

Review of Resident #51's Physician's Orders indicated but was not limited to the following:

-Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) mcg/act (Albuterol Sulfate) 2 puff inhale orally every 6 hours as needed for Asthma, dated 7/29/23.

Further review of the Physician's Orders failed to indicate Resident #51 had an order to self-administer medications and/or to keep his/her inhaler at the bedside.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Review of Resident #51's care plan failed to indicate he/she was able to self-administer his/her Albuterol inhaler and had been provided with the means to safely secure his/her Albuterol inhaler when not in use. Level of Harm - Minimal harm or potential for actual harm On the following dates of survey, the surveyor observed an Albuterol Sulfate inhaler on Resident #51's overbed table: Residents Affected - Few -6/6/24 at 9:33 A.M.

-6/10/24 at 8:15 A.M.

-6/10/24 at 3:53 P.M.

-6/11/24 at 8:02 A.M.

During an interview on 6/6/24 at 9:34 A.M., Resident #51 said he/she kept their Albuterol inhaler on his/her overbed table and used it daily as needed. Resident #51 said he/she was never told the inhaler needed to be locked in a drawer when not in use and had never been provided a way to safely store the inhaler.

During an interview on 6/11/24 at 8:09 A.M., Nurse #4 said Resident #51 should not have an inhaler on his/her overbed table and that it should be locked in the medication cart when not being used.

During an interview on 6/11/24 at 9:21 A.M., the Assistant Director of Nurses (ADON) said Resident #51 should not have medication at the bedside because he/she has never been assessed to self-administer medication and had not been instructed to lock the medication away when not in use.

During an interview 6/11/24 at 10:39 A.M., the Director of Nurses (DON) said medications should not be at

the bedside if the resident has not been assessed for self-administration and provided a way to safely secure

the medication.

2. The surveyor made the following observations:

-6/6/24 at 9:49 A.M., the Massapoag Unit, Treatment Cart was observed in the hallway with drawers facing outward, unlocked with no staff in the vicinity of the cart, residents roaming the halls

-6/6/24 at 10:44 A.M., the Massapoag Unit, Treatment Cart observed in the hallway with drawers facing outward, unlocked with staff not in the vicinity of the cart, residents roaming the halls

-6/6/24 at 11:36 A.M., a staff member approached the unlocked Massapoag Unit Treatment Cart and gathered supplies and locked the cart upon walking away

-6/11/24 at 10:19 A.M., the [NAME] Unit, Medication Cart was unlocked and unattended outside of room [ROOM NUMBER], employee was observed exiting room [ROOM NUMBER] in which the door had been closed

During an interview on 6/11/24 at 10:39 A.M., the DON said medication and treatment carts should be locked when unattended and not within eyesight of the nurse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 3. On 6/10/24 at 4:20 P.M., on the [NAME] Unit, Nurse #3 left Artificial Tears on top of the Medication Cart when she entered Resident #1's room to administer medication. Nurse #3 returned to the Medication Cart to Level of Harm - Minimal harm or retrieve an alcohol prep pad and re-entered Resident #1's room without removing the Artificial Tears from the potential for actual harm top of the medication cart. The medication cart was parked against the wall outside of the room and was not pulled into the doorway of the room, the medication cart was not within eyesight of the nurse. Residents Affected - Few

During an interview on 6/11/24 at 10:39 A.M., the DON said all medications should be locked in the medication cart when unattended.

50740

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46562

Residents Affected - Few Based on document review and interview, the facility failed to implement their facility assessment (a document assessing the capability of the facility and its resources to provide both emergency and day to day care of the population the facility currently serves). Specifically, the facility failed to maintain a bladder scanner (a noninvasive tool used to measure urine volume in the bladder) to aid in the assessment of urine volume in the bladder resulting in Resident #36 being hospitalized for four days due to a malpositioned (wrong or faulty position) Foley catheter resulting in bilateral hydroureteronephrosis (swelling of both kidneys and ureters, a thin tube that drains urine from the kidney to the bladder, which occurs when urine can't drain and builds up in the kidneys and ureters), impaired kidney function, and a urinary tract infection.

Findings include:

Review of the Facility Assessment, dated 5/21/24, physical environment and building/plant needs, section 3. 8, indicated medical supplies and resources available included a bladder scanner.

Resident #36 was admitted to the facility in February 2024 with the following diagnoses: dementia and neurogenic bladder (a urinary dysfunction in which the bladder does not empty properly in which the bladder may empty spontaneously or may not empty at all).

Review of the Minimum Data Set (MDS) assessment, dated 3/22/24, indicated Resident #36 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 1 out of 15, and had

an indwelling catheter.

Review of Resident #36's Encounter Note, written by Nurse Practitioner (NP) #1 and dated 3/12/24, indicated but was not limited to:

-Foley catheter was changed last night due to concern that urine was not draining properly.

-Nursing reports catheter has been putting out adequate amount of urine today.

-Upon my exam he/she has approximately 400 milliliters (ml) clear yellow urine in drainage bag and does not have any palpable bladder distention or suprapubic tenderness.

-Received a call this afternoon that his/her significant other was still concerned he/she was retaining urine but nursing reports he/she does not appear to have any bladder distention.

-Unfortunately, the facility does not have a bladder scanner (a noninvasive tool used to measure urine volume in the bladder).

Review of Resident #36's Interdisciplinary Team (IDT) Discharge & Recapitulation Summary, dated 3/15/24, indicated but was not limited to:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 -Resident was transferred to hospital related to distended abdomen

Level of Harm - Minimal harm or Review of Resident #36's Hospital paperwork, specifically the Discharge Summary, dated 3/18/24, indicated potential for actual harm but was not limited to:

Residents Affected - Few -Resident #36 was transferred to rehab 1.5 weeks prior and 3-4 days ago the healthcare proxy (HCP) noticed Resident #36 was having progressively worsening distention of his/her bladder which then progressed to having worsening oral intake and poor participation in physical therapy. HCP also noted diaphoresis (excessive or abnormal sweating for no apparent reason) and he/she was complaining of difficulty urinating.

-In the Emergency Department, Resident #36 was mildly tachycardic (a heart rate greater than 100 beats per minute) to 106, and his/her labs showed a serum creatinine (a blood or urine test that indicates how well your kidneys are filtering waste from your blood ) of 2.12 (the typical range for serum creatinine is: for adult men, 0.74 to 1.35 milligrams/deciliter and for adult women, 0.59 to 1.04 milligrams/deciliter) and a blood urea nitrogen (BUN, test reveals how well your kidneys are working) of 67 (a BUN of 6 to 24 milligrams/deciliter is considered normal), his/her urinalysis (a review of the urine) was grossly infected and his/her abdominopelvic computerized tomography scan (CT scan, a type of imaging that uses X-ray techniques to create detailed images of the body) indicated bilateral hydronephrosis and a distended urinary bladder with

the Foley catheter positioned within the tip of the penile urethra.

-Foley catheter was replaced and 2500 milliliters of urine was removed with improvement in his/her abdominal distention. He/she was administered antibiotics and admitted to for further management.

-Creatinine was down to 0.63 after Foley catheter decompression.

-Renal ultrasound was obtained on 3/17/24 to reassess hydronephrosis and indicated no evidence of hydronephrosis on the right (which had been on the CT scan) and bladder was decompressed.

Review of Resident #36's Encounter Note, written by NP #1 and dated 3/19/24, indicated but was not limited to:

-He/she was sent to the Hospital on 3/15/24.

-He/she was found to have bilateral hydroureteronephrosis, distended urinary bladder, and fecal loading.

-Foley catheter was changed and 2500 milliliters (mL) of urine was removed.

-He/she returned to the facility on [DATE REDACTED].

During an interview on 6/11/24 at 1:41 P.M., the Director of Nurses (DON) said he was not sure if the facility had a bladder scanner or not, that he had not encountered needing one (review of Health Care Facility Reporting System indicated he had been the DON since 2/5/24). The Director of Clinical Services said all facilities are different and she could not speak to the status of a bladder scanner at that facility. The DON said Resident #36 was transferred to the hospital on 3/15/24 around 11:30 A.M. due to a distended abdomen and abnormal test results.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 During an interview on 6/11/24 at 1:31 P.M., Nurse #4 said the facility did not have a bladder scanner.

Level of Harm - Minimal harm or During an interview on 6/11/24 at 3:36 P.M., the Regional Director of Operations said the facility did not have potential for actual harm a bladder scanner. The surveyor and the Regional Director of Operations reviewed the Facility Assessment which indicated a bladder scanner was available to care for the facility's residents and the Regional Director Residents Affected - Few of Operations said he would follow up with the surveyor.

During an interview on 6/11/24 at 5:11 P.M., the Regional Director of Operations confirmed the facility did not have a bladder scanner and said it must have broken.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue.

Level of Harm - Minimal harm or 34145 potential for actual harm Based on document review and interview, the facility failed to ensure their arbitration agreement provides for Residents Affected - Some the selection of a neutral venue that is convenient to both parties.

Findings include:

Review of a list of residents with signed Arbitration Agreements, provided by the facility on 6/6/24 and 6/13/24, indicated a total of 45 residents/representatives had signed the facility's binding Arbitration Agreement.

Review of the Arbitration Agreement in use by the facility until 6/5/24, failed to indicate the residents or their representatives had the right to a neutral venue agreed upon by both parties.

During an interview on 6/13/24 at 3:30 P.M., Corporate Staff #2 said that last week they updated the facility's Arbitration Agreement to provide for the selection of a neutral venue that is convenient to both parties. He said they have started the process of having residents/representatives that previously signed the Arbitration Agreements sign the updated version. Review of a list of residents provided by Corporate Staff #2 indicated that 11 of 45 residents had signed the updated Arbitration Agreement.

During interviews on 6/13/24 at 4:00 P.M. and 4:15 P.M., the Director of Admissions (DOA) said the facility's Arbitration Agreement was updated last week to include the selection of a neutral venue that is agreed upon by both parties. The DOA said she drafted a letter identifying the changes made to the agreement and sent

the letter and new agreement to residents/representatives who previously signed it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48695 potential for actual harm Based on document review and interview, the facility failed to maintain an infection prevention and control Residents Affected - Many program to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to:

1. Ensure a water management program was implemented to minimize the risk of Legionella (bacteria that can cause Legionnaires' disease, a serious type of pneumonia) and other opportunistic pathogens in building water systems by accurately measuring and documenting water temperatures;

2. For Resident #211, ensure staff wore personal protective equipment (PPE) and perform hand hygiene as required for Contact Precautions (infection control precautions used for patients who may be infected with certain infectious agents for which additional precautions are needed to prevent infection transmission); and

3. For Resident #35, properly store an oral syringe to minimize the risk of contamination.

Findings include:

1. Review of the facility's policy titled Legionella, last revised April 2022, indicated but was not limited to the following:

- Policy: Our facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella.

- Guidelines:

1. As part of the infection prevention and control program, the facility has a water management program, which is over seen by the water management team.

3. The purpose of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease.

4. The water management program used by the facility is based on applicable federal and state regulations.

5. The water management program may include the following elements:

e. Specific measures used to control the introduction and/or spread of Legionella (e.g., temperature, disinfectants);

f. The control limits or parameters that are acceptable and that are monitored;

i. A plan for when control limits are not met and/or control measures are not effective.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Review of the facility's Legionella Preventive Procedures listed on the Legionella Identified Dead Ends Monthly checklist, undated, indicated but was not limited to: Level of Harm - Minimal harm or potential for actual harm - Hot water tanks should be above 140 degrees Fahrenheit, and we must maintain circulatory hot water at 120 degrees Fahrenheit for the floors. Residents Affected - Many - When Flushing Turn the Hot Water on and record temperature. Acceptable range is 77 degrees Fahrenheit and 113 degrees Fahrenheit.

- After 5 minutes of flushing move to the next site

Further review of the Legionella Identified Dead Ends Monthly Checklist indicated but was not limited to the following:

- 12/07/23 The facility ran the water in the basement for five minutes but failed to document the temperature of the water.

- 12/15/23 The facility ran the water in the basement for five minutes but failed to document the temperature of the water.

- 12/20/23 The facility ran the water in the basement for five minutes but failed to document the temperature of the water.

- 12/28/23 The facility ran the water in the basement for five minutes but failed to document the temperature of the water.

- 3/7/24 The facility ran the water in both hot water tanks for five minutes but failed to document the temperature of the water.

- 3/14/24

1. The facility ran the water in both hot water tanks for five minutes but failed to document the temperature for both hot water tanks.

2. The temperature of the water in the basement was 70 degrees Fahrenheit after running for five minutes.

- 3/21/24

1. The facility ran the water in both hot water tanks for five minutes but failed to document the temperature for both hot water tanks.

2. The temperature of the water in the basement was 71 degrees Fahrenheit after running for five minutes.

3. The temperature of the water on the Massapoag was 70 degrees Fahrenheit after running for five minutes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 - 3/28/24

Level of Harm - Minimal harm or 1. The facility ran the water in both hot water tanks for five minutes but failed to document the temperatures potential for actual harm for both hot water tanks.

Residents Affected - Many 2. The temperature of the water in the basement was 71 degrees Fahrenheit after running for five minutes.

3. The temperature of the water on the Massapoag was 73 degrees Fahrenheit after running for five minutes.

- 4/12/24

1. The temperature of the water in the basement was 68.3 degrees Fahrenheit after running the water for five minutes.

3. The temperature of the water on the Massapoag was 70 degrees Fahrenheit after running the water for five minutes.

- 4/18/24

1. The facility ran the water in the basement for five minutes but failed to document the temperature of the water.

2. The temperature of the water on the Massapoag was 71 degrees Fahrenheit after running for five minutes.

- 4/25/24

1. The facility ran the water in the basement for five minutes but failed to document the temperature of the water.

2. The temperature of the water on the Massapoag was 71 degrees Fahrenheit after running for five minutes.

- 5/1/24

1. The temperature of the water in the basement was 70 degrees Fahrenheit after running for five minutes.

2. The temperature of the water on the Massapoag was 70 degrees Fahrenheit after running for five minutes.

- 5/10/24

1. The temperature of the water in the basement was 70 degrees Fahrenheit after running for five minutes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 2. The temperature of the water on the Massapoag was 70 degrees Fahrenheit after running for five minutes.

Level of Harm - Minimal harm or - 5/17/24 potential for actual harm 1. The temperature of the water in the basement was 70 degrees Fahrenheit after running for five minutes. Residents Affected - Many 2. The temperature of the water on the Massapoag was 70 degrees Fahrenheit after running for five minutes.

- 5/24/24

1. The temperature of the water in the basement was 70 degrees Fahrenheit after running for five minutes.

2. The temperature of the water on the Massapoag was 70 degrees Fahrenheit after running for five minutes.

- 5/31/24

1. The temperature of the water in the basement was 70 degrees Fahrenheit after running for five minutes.

2. The temperature of the water on the Massapoag was 70 degrees Fahrenheit after running for five minutes.

During an interview on 6/11/24 at 4:21 P.M., the Maintenance Director said the process was to let the hot water run for five minutes then check the temperature and record the temperatures of the two water tanks, in

the basement, and on the Massapoag unit. The Maintenance Director and surveyor reviewed the Legionella Identified Dead Ends Monthly Checklist for the above dates. The Maintenance Director said he should have recorded the temperatures after running the water for five minutes and that he would sometimes take the temperature of the water on the cold side. The Maintenance Director said he should have taken the temperature of the hot water instead of the cold water.

During an interview on 6/11/24 at 4:21 P.M., the Regional Maintenance Director said he had been responsible for taking the temperature of water in the basement in December and he should have recorded

the temperature of the two hot water tanks but did not.

During an interview on 6/12/24 at 2:19 P.M., the Administrator said the expectation was for the water temperatures to be taken and recorded accurately and per policy. The Administrator said she was aware that

the Maintenance Director would at time take the temperature of the cold water and she has not reviewed the temperature logs for the last few months and should have.

46562

2. Review of the facility's policy titled Infection Control, dated as revised 5/23, indicated but was not limited to

the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 -When there is likely exposure to spores (reproductive cells that can develop into new organisms) (i.e., Clostridium difficile (C-diff, a spore forming toxin that can develop in the intestines after antibiotic use and Level of Harm - Minimal harm or causes watery diarrhea) Note: Alcohol-based hand rubs are ineffective against spores. For the effective potential for actual harm mechanical removal of spores, wash hands for 30-60 seconds with soap and water or 2% Chlorhexidine Gluconate (a germicidal liquid). Residents Affected - Many

Review of the facility's policy titled Isolation - Categories of Transmission-Based Precautions, dated as revised 4/22, indicated but was not limited to the following:

-In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's room.

-Examples of infections requiring Contact Precautions include, but are not limited to: diarrhea associated with Clostridium difficile.

-In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean, not sterile) when entering the room.

-Remove gloves before leaving the room and perform hand hygiene.

-Wear a disposable gown upon entering the Contact Precautions room or cubicle.

-The facility will implement a system to alert staff to the type of precaution the resident requires.

Review of the Centers for Disease Control and Prevention (CDC) Contact Precautions sign, undated, indicated but was not limited to:

-Everyone must: clean their hands, including before entering and when leaving the room.

-Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person.

Resident #211 was admitted to the facility in June 2024 with diagnoses including enterocolitis due to C-diff and sepsis (an infection of the bloodstream).

Review of the Physician's Orders for Resident #211 indicated but was not limited to the following:

-Contact or droplet precautions for C-Diff. The resident remains in his/her room alone. All services are brought to the resident in room (e.g. rehabilitation, activities, dining, etc.) every shift for infection- C-diff, dated 6/7/24;

-Contact Precautions, dated 6/6/24;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 -Maintain contact precautions for C-diff (staff to perform hand hygiene upon entering and exiting room and to don (put on) appropriate Personal Protective Equipment (PPE) gowns and gloves, don eye protection as Level of Harm - Minimal harm or indicated for risk of splashes and sprays of bodily fluid. Perform Hand Hygiene by washing hands with soap potential for actual harm and water every shift for Precautions maintain PPE precaution [SIC], dated 6/6/24

Residents Affected - Many Review of the Care Plan for Resident #211 indicated but was not limited to the following:

-Focus: Resident has active infection and is being treated in attempt to prevent the spread. Is symptomatic and/or has a positive test indicating contagious stage (stool, C-diff).

-Interventions: Transmission based precaution (contact)

On the following dates of the survey, the surveyor observed:

-6/6/24 at 10:20 A.M., Social Worker #1 standing in Resident #211's room talking to the Resident with no PPE donned. At 10:28 A.M., the Social Worker left the room and did not perform hand hygiene. A CDC Contact Precautions sign was observed on the doorframe and a PPE bin was located outside of the door.

-6/10/24 at 8:19 A.M., Certified Nursing Assistant (CNA) #2 was observed in Resident #211's room changing

the television channel with no PPE on. CNA #2 then exited the room with Resident #211's breakfast tray, holding it with both hands. CNA #2 then used one hand to open the tray cart and placed the breakfast tray on

the cart. CNA #2 then performed hand hygiene with alcohol-based hand rub and proceeded down the hallway. A CDC Contact Precautions sign was observed on the doorframe and a PPE bin was located outside of the door.

During an interview on 6/12/24 at 11:18 A.M., the Infection Preventionist said when a resident is suspected or confirmed to have C-diff, the staff must wear a gown and gloves and wash their hands with soap and water and utilize bleach wipes when cleaning equipment. The Infection Preventionist said a C-diff meal tray should not have been carried down the hallway.

During an interview on 6/11/24 at 9:21 A.M., the Assistant Director of Nurses (ADON) said, that residents on contact precautions related to C-diff, staff should don gown and gloves when entering the resident's room and remove the PPE before exiting the room. The ADON said that staff should wash their hands with soap and water after removing their PPE to prevent the spread of C-diff.

3. On 6/11/24 at 7:23 A.M., on the [NAME] Unit Medication Cart, the surveyor observed:

-One bottle of liquid Atovaquone (an antimicrobial medication) Oral Suspension belonging to Resident #35 with an oral syringe secured to the bottle by an elastic band. The syringe tip was uncapped and exposed.

During an interview on 6/11/24 at 7:23 A.M., Nurse #4 said that the syringe tip should be covered and should not be exposed.

During an interview on 6/11/24 at 10:39 A.M., the Director of Nurses (DON) said oral syringes should be covered or stored in a closed bag to prevent potential contamination.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 43 225134 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225134 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Foremost at Sharon LLC 259 Norwood Street Sharon, MA 02067

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 50740

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Many

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 43 225134